Vertigo disoreinatation

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• A 58 year old presenting to us, stating
 that she awoke that day feeling that the
 room was spinning . She Had vomited
 twice. She seemed anxious was unsteady
 in her feet and was hyperventilating. She
 didn’t have fever, but had a sore throat,
 slight difficulty swallowing, slight
 hoarseness and a red throat. Hallpikes test
 induced vertigo and nystagmus.
• Vertigo is defined as the illusory sense of
  movement or disorientation, indicates
  disorder of the labyrinth or brainstem
• Presyncope is defined as a sense of near
  faint typically due to transient hypotension
• Disequilibrium in the elderly is often
  described as nonspecific slight
  unsteadiness, particularly in turning and
  indicates poor balance and strength
 Is it common?
• Vertigo is a common condition in the community
• A fulltime GP can see 10-20 cases/year
• The diagnostic challenge is to differentiate peripheral from
  very uncommon but very serious central causes such as
  brainstem stroke
Main clinical features to be elicited in
the presence of acute vertigo are

•   No history of hearing loss or tinnitus?
•   No headache?
•   Onset and duration of vertigo?
•   Whether it is positional or sustained?

Nystagmus during Hallpike’s manoeuvre,
eye movement normal (except horizontal
No Horners, TMs normal, No new onset
 deafness, No facial weakness , dysphagia,
 dysphonia, must be able to walk even with
 unsteadiness, no limb paresis, objective
 ataxia or sensory loss
Red flags to look for on

• Any central neurological symptoms or
• Anew type headache
• Acute deafness
• Vertical nystagmus
• A 40 year old lady presenting with, sudden
  onset of vertigo on turning the head, with
  nausea. Halpikes shows rotatory
  nystagmus. No headache, no vomiting, no
  deafness, Rhombergs negative, gait
• A 45 year old lady presenting with
  sustained vertigo, with unidirectional
  horizontal nystagmus, no hearing loss or
  tinnitus or neurological signs, has nausea
  and vomiting
• What is the main differential diagnosis?
• Cerebellar stroke, of a case study of 240
  patients with cerebellar stroke, 25 had
  vertigo as sole feature. A simple test
  called the ‘head thrust test’ tests the
  vestibuloocular reflex and is always
  abnormal in vestibular neuronitis. It was
  normal in 24/25 of the cerebellar strokes.
• A 25 year old man presenting with vertigo,
  hearing loss and tinnitus with symptoms
  of urti, no neurological symptoms, head
  thrust is positive, what is the likely
  diagnosis, what will you do?
• A 80 year old man presenting with vertigo
  unilateral hearing loss, tinnitus, headache,
  facial pain and tingling, what needs to be
  ruled out
• A 50 year old presenting with vertigo,
  tinnitus and fluctuating hearing loss with a
  sensation of aural pressure

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